Provider Demographics
NPI:1003997420
Name:GIBBES, JACQUELINE A (MD)
Entity Type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:A
Last Name:GIBBES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:CHELSEA
Mailing Address - State:MA
Mailing Address - Zip Code:02150-2247
Mailing Address - Country:US
Mailing Address - Phone:617-660-6600
Mailing Address - Fax:617-887-2794
Practice Address - Street 1:1000 BROADWAY
Practice Address - Street 2:
Practice Address - City:CHELSEA
Practice Address - State:MA
Practice Address - Zip Code:02150-2247
Practice Address - Country:US
Practice Address - Phone:617-660-6600
Practice Address - Fax:617-887-2794
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA49818208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA99220101OtherNETWORK HEALTH
MA3003167Medicaid
MAE05924OtherBLUE CROSS BLUE SHIELD
MA3003167Medicaid